March 9, 2020

Background: Oxygen therapy is frequently used in the emergency department for the treatment of hypoxia and respiratory failure and can be delivered in a variety of ways. Conventional oxygen therapy (COT) via nasal cannula is often a first line treatment, but has some drawbacks, including inability to deliver a precise concentration and volume of oxygen, inability to deliver high enough concentration and volume of oxygen, inability to heat and humidify, and poor tolerance.  While it is able to deliver more precise, high flow oxygen, noninvasive ventilation (NIV) also presents a comfort challenge for many patients. High flow nasal cannula (HFNC) has been introduced as an alternative to COT and NIV. It can be used to deliver heated, humidified oxygen at high rates (up to 60 L/min) and maintain a set oxygen fraction. Prior randomized controlled trials (RCTs) and meta-analysis comparing HFNC to COT and NIV have demonstrated conflicting results. Additionally, none of these previous meta-analyses have evaluated emergency department (ED) patients.

September 5, 2019

Background: Working in the emergency department means frequently performing painful procedures on patients, often we turn to procedural sedation to make these procedures more tolerable for patients, families and clinicians alike.  Ketamine is often used for this purpose, particularly in pediatrics, however, many clinicians are reluctant to use this agent due to concerns for recovery agitation or the dreaded “emergence phenomenon.” Clinicians often turn to the co-administration of various agents, including benzodiazepines and antipsychotics, to blunt this effect.  The definition of recovery agitation and the means by which it is measured are inconsistent in the previous literature, leading to a dearth of evidence as to whether the practice of co-administration of medications is effective in reducing recovery agitation.

January 24, 2019

Background: This is a guest post from two of our friends all the way in Italy.  They have actually sent several revisions of this post as a way to help learners focus on different aspects of FOAMed.  One of the major caveats the authors mentioned is that FOAM covers most of the coolest parts of EM, but there are other topics that are important as well.  The authors advocate for a compilation of resources into a simple syndication reader (i.e. Feedly) and podcast application (i.e. Downcast, Overcast, etc).  When searching for topics consider using FOAM search. Finally, study and focus on FOAM topics that you like and need:
  1. Like = your passions, what you’re best at
  2. Need = what you’re worst at or scared of

September 24, 2018

Background: The assessment and management of the acute onset headache from the perspective of the emergency department is a point of contention and discussion commonly faced by emergency providers.  The Ottawa Subarachnoid Hemorrhage Rule is a clinical decision making instrument that was created to help identify patients who need further workup beyond a basic history and physical exam. It does not define the extent of workup required, specifically whether or not a CT versus CT and LP are required to rule out a subarachnoid hemorrhage. In a 2010, Perry et al (1) published results from a prospective cohort study which attempted to formulate a collection of sensitive, high risk characteristics that could identify patients who require workup for subarachnoid hemorrhage. The three separate collections of high-risk features were all found to be highly sensitive (100% sensitivity with 95% CI) and so further investigation was found to be warranted. An additional prospective cohort by Perry et al (2) was designed to further assess the sensitivity, specificity, and overall applicability of these 3 decision making rules to identify patients who require subarachnoid hemorrhage workup. The initial results of this study showed one of the clinical decision making instruments to have a superior sensitivity of 98.5% (95% CI, 94.6%-99.6%). The rule was then redefined to include “thunderclap” headache and limited neck flexion on exam, and then reassessed utilizing a recursive partitioning analysis in order to obtain 100% sensitivity. The Perry et al 2017 (3) study was designed to validate the collection of high-risk characteristics this group has identified as warranting possible workup for subarachnoid hemorrhage.

June 19, 2017

Background: In 2002, the New England Journal of Medicine published two studies that changed the management of post-cardiac arrest patients by showing improved outcomes in patients treated with therapeutic hypothermia (32°C-34°C) for at least 24 hours. (Bernard 2002, Hypothermia 2002).  The landscape changed again in 2013 with the publication of the Targeted Temperature Management (TTM) trial in the New England Journal, which compared post-cardiac arrest hypothermia at 32-34°C and at 36°C and found no difference in outcomes (Nielson 2013). After the publication of the TTM trial, many hospitals changed their cooling protocols to a target temperature of 36°C, however, recently it has been shown that this may pose an increased risk of fever. (Cassamento 2016).
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